Regional Perinatal Care:Regional Perinatal Care:Regional Perinatal Care:Regional Perinatal Care:
What do we call the components?What do we call the components?
Lillian R. Blackmon, MD
Perinatal Regionalization MeetingOctober 28, 2009Washington, DC
RegionalizationRegionalization
What? Organization of health care resources and
delivery within a defined geographic area
Why?T id i k i t t t t l To provide risk appropriate care to a total
population to achieve the best outcomes in the most cost efficient manner
How? Voluntary, regulation, market forces
History of the ConceptHistory of the Concept
1965 Regional Medical Programs in US
Cancer, Stroke, Heart Disease
1966 Prevention of Rh Isoimmunization
Chown, Manitoba Province
1970 Proposed for Perinatal Health Care
Silverman, Swyer
1971 AMA House of Delegates Statement
Centralized Community or RegionalizedPerinatal Intensive Care
1973 66th R C f1973 66th Ross ConferenceRegionalization of Perinatal Care
History of Newborn Services:History of Newborn Services:Concepts and StandardsConcepts and Standards
AAP Committee on Fetus and NewbornAAP Committee on Fetus and Newborn1948-77 Hospital Care of Newborns1980 Level II Units2004 Levels of Newborn Care2004 Levels of Newborn Care
Committee on Perinatal Health1976 Toward Improving the Outcome of
Pregnancy I1993 Toward Improving the Outcome of
P IIPregnancy II
AAP COFN & ACOG CoOP1983-2007 Guidelines for Perinatal Care
Early State RegionalizationEarly State RegionalizationEarly State RegionalizationEarly State Regionalization
Arizona
Wisconsin
Iowa
KansasKansas
North CarolinaNorth Carolina
Traditional TerminologyTraditional Terminology
Level I (TIOP I) – Basic (TIOP II)“Uncomplicated labor and delivery of normal Uncomplicated labor and delivery of normal
term newborn…uncomplicated neonatal care of infants of appropriate gestational
i h d i h h weight…term…do not require other than emergency resuscitation”
Consultation and transfer: < 35 weeks Consultation and transfer: < 35 weeks gestation; birthweight < 2000 gms
Traditional TerminologyTraditional Terminology
Level II (TIOP I) – Specialty (TIOP II)Level II (TIOP I) Specialty (TIOP II)“Full range of maternal and neonatal services
for uncomplicated patients, for the majority of maternal complicated obstetrical problems and certain types of neonatal illnesses…resuscitation
short-term assisted ventilation with bag and …short term assisted ventilation with bag and mask…treating mildly ill infants…”“referral of women in labor <34 weeks gestation …infants <34 weeks, < 2000 grams” (TIOP I)<32 weeks gestation, < 1500 grams” (TIOP II)
Traditional TerminologyTraditional Terminology
Level III (TIOP I) – Subspecialty (TIOP II)“Provide care for all types of maternal-fetal and o de ca e o a types o ate a eta a d
neonatal illnesses and abnormalities” (TIOP I)
“Provide comprehensive perinatal care servicesfor both admitted and transferred mothers and neonates of all risk categories”neonates of all risk categories
State Definitions for Levels State Definitions for Levels of Neonatal Servicesof Neonatal Servicesof Neonatal Servicesof Neonatal Services
S l h l h iStates regulate health care servicesand facilities
License hospitalsPromulgate State Health Plans
Distribution of servicesDistribution of services
Allocation of resources
Approve facility expansion and Approve facility expansion and construction
Implement Title V programsImplement Title V programsCertification of specialty servicesReimbursement for specialty care
State Definitions for Levels State Definitions for Levels of Neonatal Servicesof Neonatal Servicesof Neonatal Servicesof Neonatal Services
Sources for Definitions of LevelsSources for Definitions of Levels
Distribution: 24 single; 9 two or more
Licensure: 18; 2 additional refer to other state source
Certificate of Need/State Health Plan:13; 4 exclusively13; 4 exclusively
State Health Department/affiliate:14 9 l i l14; 9 exclusively
State Definitions for Levels State Definitions for Levels of Neonatal Servicesof Neonatal Servicesof Neonatal Servicesof Neonatal Services
None Named Two Levels Three Levels Four Levels Five or Beds/Units More Levels
Arkansas Alaska Oklahoma California Alabama Arizona New Hampshire Connecticut Rhode Island Hawaii Florida ColoradoSouth Dakota District of Wisconsin Kansas Georgia DelawareSouth Dakota District of Wisconsin Kansas Georgia Delaware
Columbia Idaho Kentucky Louisiana IllinoisMichigan Maine Massachusetts Indiana Minnesota Mississippi New Jersey IowaMi i N d N Y k M l dMissouri Nevada New York MarylandMontana Ohio North Carolina South CarolinaNebraska Pennsylvania Tennessee WashingtonNew Mexico Texas VirginiaNorth Dakota Utah Oregon VermontWest VirginiaWyoming
State Definitions for Levels State Definitions for Levels of Neonatal Servicesof Neonatal Servicesof Neonatal Servicesof Neonatal Services
L l i l i d b hLevels terminology: numeric, word, both
Range: 2 – 6 levelsRange: 2 – 6 levels
Variation:Variation:Designate some Level III/Subspecialty as Regional
Perinatal Centers Advanced level of care above base level for:
Respiratory support, care of VLBW infantsS bdi id f t diti l th l lSubdivide one or more of traditional three levels
State Definitions for Levels State Definitions for Levels of Neonatal Servicesof Neonatal Servicesof Neonatal Servicesof Neonatal Services
Functional Criteria
25 states use one or more to differentiate levels:Population characteristicsPopulation characteristics
Birth Weight and/or Gestational Age
R i t Respiratory careSupplemental O2 concentration or duration
Mode of ventilation or duration
Neonatal surgery, cardiac surgery, ECMO
8 states use non-specific termsMild, moderate, severe
State Definitions for Levels State Definitions for Levels of Neonatal Servicesof Neonatal Servicesof Neonatal Servicesof Neonatal Services
Utilization CriteriaUt at o C te a18 states have one or more requirements:
Capacity: Minimum number of bed type per unit or per population base
V lVolume: Deliveries or live births per year
Occupancy: average daily census or percent capacitycapacity
Case Mix: VLBW admissions, VLBW patient days, ventilator days, or neonatal surgeries per year
State Definitions for Levels State Definitions for Levels of Neonatal Servicesof Neonatal Servicesof Neonatal Servicesof Neonatal Services
Compliance License CON/SHP SHD/Affiliated ProgramMeasures Renewal Approval CertificationMeasures Renewal Approval Certification
Number of States 18, 10† 13, 4† 14, 9†
Renewal 1 5 yrs Application only 14Renewal 1-5 yrs Application only 14MF: annual 1-5 yrs
Mandated 11 states 7 states 2 regional centers onlyReporting
On-site 11 states 2 states 7 statesInspections 4 initial 3, regional centers onlyInspections 4 initial 3, regional centers only
7 episodic
Self Designation 1 state 1 state 4 states
† Single source MF = Most Frequent
ArizonaArizona
Arizona Perinatal Trust http://azperinatal.org
private, non-profit organization – certifies perinatal care levels of hospitals
Arizona Perinatal Regional System, Inc.“performing corporation of APT”; promulgates Recommendations and Guidelines for Perinatal Care Recommendations and Guidelines for Perinatal Care Centers; evaluates regional perinatal system function; operates Voluntary Certification Program
Bureau of Women’s and Children’s HealthHigh Risk Perinatal/Newborn Intensive Care Program, g / g ,contracts with certified hospitals and physicians for in-hospital care www.azdhs.gov/owch/hiriskper.htm
IllinoisIllinois
Regionalized Perinatal Health Care CodeRegionalized Perinatal Health Care CodeImplements Developmental Disability Prevention Act
Perinatal Advisory Committee to Department of Public Health
Standards for Perinatal Care applied in health facilities planning, licensure, hospital certification, funding for patient care
www.ilga.gov/commission/jcar/admincode/077/07700640sections.htmlwww.ilga.gov/commission/jcar/admincode/077/07700640sections.html
FloridaFlorida
Regional Perinatal Intensive Care Centers Regional Perinatal Intensive Care Centers Program
comprehensive, statewide perinatal delivery co p e e s e, state de pe ata de e ysystem; Florida DOH CMS administers
focuses on perinatal care of high risk pregnancies and neonatesand neonates
certifies both hospitals and physicians for reimbursement through Title 5 and Medicaid
11 RPICCs and 18 high risk obstetric clinics
www doh state fl us/cms/rpiccindex htmlwww..doh.state.fl.us/cms/rpiccindex.htmlwww.doh.state.fl.us/cms/rpicc.handbook.pdf
State Definitions for Levels State Definitions for Levels of Neonatal Servicesof Neonatal Servicesof Neonatal Servicesof Neonatal Services
Research Design - Systematic search of websites for all 50 states and DC
Regulations for hospital licensure Regulations for Certificate of Need applicationRegulations for Certificate of Need applicationState health facility planning documentsState MCH funded patient services or programsState MCH funded patient services or programsPublications by affiliated non-governmental
state perinatal health entities
State Definitions for Levels State Definitions for Levels of Neonatal Servicesof Neonatal Servicesof Neonatal Servicesof Neonatal Services
Definition Criteria for Levels Designation
Specific language to designate multiple patient Specific language to designate multiple patient care services (not physical facilities or units)
M lti l i l l d ib dMultiple care service levels described
Description of graduated complexity of care p g p ycapabilities or intensity of care requirements
State Definitions for Levels State Definitions for Levels of Neonatal Servicesof Neonatal Servicesof Neonatal Servicesof Neonatal Services
Functional Criteria: Birth Weight Gestational AgeNumber of States 17 17
Service LevelService LevelLow – I, Basic Range: > 1.8 - > 2.5 kg Range: > 34 - > 36 wks
MF: > 2.5 kg MF: > 36 wks– Advanced, IEQ > 1.8 kg > 35 wks
Mid – II, IIa Range: > 1.0 kg - > 1.5 kg Range: > 30 - > 34 wksSpecialty MF: > 1.5 kg MF: > 32 - > 34 wks
– IIb > 1.25 kg > 30 wks
High – IIIa >1 0 kg > 28 wksHigh IIIa >1.0 kg > 28 wks
*MF = Most Frequent
State Definitions for Levels State Definitions for Levels of Neonatal Servicesof Neonatal Servicesof Neonatal Servicesof Neonatal Services
Functional Criteria: Neonatal Surgery Cardiac Surgery ECMONumber of States N* – 20 S – 1 N – 10 S – 5 N – 3
S – 5Service Level
MidMid– Advanced, II EC, II EQ with pediatric surgeonIIb 2 statesIIb 2 states
High – III 15 states 8 states 2 states– IIIa Minor, 3 states– IIIb 3 states– IIIc, IIId 5 states 4 states 3 states – IV 2 states 3 states 2 states– RPC 11 states 10 states
*N= Neonatal S = Separate
State Definitions for Levels State Definitions for Levels of Neonatal Servicesof Neonatal Servicesof Neonatal Servicesof Neonatal Services
Functional Criteria: Oxygen Ventilatory SupportFunctional Criteria: Oxygen Ventilatory SupportNumber of states 10 22Service Level
Low – I, Basic Range: Limited, 40% Stabilization onlyLow I, Basic Range: Limited, 40% Stabilization onlyHood, Nasal Cannula prior to transport
Mid – II, IIa Range: < 50% - < 80% Limited, Emergent pending Specialty Hood, NC transport, With consultp y , p ,
< 6 hr - < 4d Short term
–IIb, II R, NCPAP, CMV, CMV < 24 hr II EC, II EQ CMV with neonatologistII RN
High – IIIa CMV onlyHigh IIIa CMV only– III, IIIb, IIIc CMV, HFV, iNO
IV, RPC CMV, HFV, iNO
State Definitions for Levels State Definitions for Levels of Neonatal Servicesof Neonatal Servicesof Neonatal Servicesof Neonatal Services
Utilization Criteria: Capacity Volumebeds/unit deliveries/yr live births/yrbeds/unit deliveries/yr live births/yr
Number of States 10 6 5Service LevelLow – Advanced 600
Mid– II, Intermediate > 4-10 Range: > 500 Range: 1000– Specialty, IIa intermediate –2000 –2000 p y,
– CPC, Intermediate 15 special care– Advanced, IIb Range: 1000->1500 1000
High– Advanced, IIR, IIN > 10– III, Subspecialty 9 – 15 Range: 1500-2500 1500– RPC 4/1000 LB Range: 8000-10000RPC 4/1000 LB Range: 8000 10000
8/1000 LBGreen = region or district
State Definitions for Levels State Definitions for Levels of Neonatal Servicesof Neonatal Servicesof Neonatal Servicesof Neonatal Services
Utilization Criteria: Occupancy Case MixADC % Capacity High Risk Volumep y g
Number of States 3 5 5Service Level
Mid– II Specialty IIa 1-2 Level II Range: 65-90% > 40 VLBW admits/yrII, Specialty, IIa 1 2 Level II Range: 65 90% > 40 VLBW admits/yr
> 1200 patient days/yr– CPC Intermediate 6 intermediate– Advanced, IIb, 2-4 Level II > 125 VLBW ventilated
or neonatal surgery/yr> 72 ventilator days/yrto ventilate < 1 kg
High– IIR , IIN, IIIa > 2000 patient days/yr– III, Subspecialty > 10 Range: 75-80% > 4000 patient days/yr
L l II & III 250 VLBW til t dLevel II & III > 250 VLBW ventilatedor neonatal surgery/ yr
Green = Both Facility and Regional